Uvular and tonsillar pillar mucosal necrosis as a cause of severe sore throat after orotracheal intubation.

We report the case of a 57-year-old man who underwent prostate brachytherapy under intravenous general anaesthesia. The patient gave permission for the report of this case and publication of the photo (Figure 1). His preoperative airway history and oropharyngeal examination was unremarkable. The trachea was successfully intubated at the first attempt (8.0 mm internal diameter tube, Macintosh #3 blade). He was intubated for a total of 150 minutes. No suctioning of the pharynx was performed at the end of the procedure. His postoperative period was uneventful except for a severe sore throat which the patient first reported on his arrival in the recovery room. His major complaint was a sensation of a foreign body in his throat without airway or breathing problems. Clinical examination of his oropharynx combined with flexible fibroscopy showed an elongated swollen uvula with ulcerations and diffuse fibrinous spots. The posterior tonsillar pillars were also swollen and ulcerated (Figure 1). The rest of the oropharynx and larynx was normal. The patient was treated conservatively with intravenous antibiotics and corticosteroids, as well as traditional postoperative pain management including paracetamol, diclofenac and opiates as needed. The sore throat resolved within 48 hours, but the sensation of a pharyngeal foreign body persisted for days, leading to a fear of suffocation by the patient causing anxiety and disturbed sleep. The patient was discharged from hospital on day 5 and on review on day 10 his symptoms had resolved completely.

Uvular necrosis has been previously described (1). The injury is thought to result from an impingement on the uvula by the device against the hard palate or posterior pharynx, leading to ischaemia. However, to our knowledge, necrosis of the mucosa over both the uvula and tonsillar pillars after orotracheal intubation has not previously been reported.

Sore throat is common after endotracheal intubation and has been reported to be as high as 40%2. Another possible mechanism involves uvular injury due to aggressive oropharyngeal suctioning (3). Treatment is classically conservative with concomitant use of steroids, antihistamines, antibiotics and/or topical adrenaline administration (4,5). Excision of the necrotic portion the uvula has been described (4) and could be an alternative to conservative therapy if the necrotic part of the uvula is sharply demonstrated. Regardless of the treatment option, full recovery should be expected within 15 days (5).

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Clinicians should consider the possibility of ischaemia or necrosis of oropharyngeal midline structures if a severe sore throat persists after tracheal intubation. Avoiding pressure on the uvula by the tracheal tube and avoiding rough oropharyngeal suction may reduce the incidence of this complication.

References

(1.) Atkinson CJ, Rangasami J. Uvula necrosis--an unusual cause of severe postoperative sore throat. Br J Anaesth 2006; 97:426427.

(2.) Biro P, Seifert B, Pasch T. Complaints of sore throat after tracheal intubation: a prospective evaluation. Eur J Anaesthesiol 2005; 22:307-311.

(3.) Bogetz MS, Tupper BJ, Vigil AC. Too much of a good thing: uvular trauma caused by overzealous suctioning. Anesth Analg 1991; 72:125-126.

(4.) Calikapan GT, Karakus F. Uvula necrosis after endotracheal intubation for rhinoplasty. Aesthetic Plast Surg 2008; 32:710-711.

(5.) McHardy FE, Chung F. Postoperative sore throat: cause, prevention and treatment. Anaesthesia 1999; 54:444-453.

J.-C. F. B. Salengros

W. El Founas

C.-E. Velghe-Lenelle

E. Willemse

M. Sosnowski

G. Andry

A. Digonnet

Brussels, Belgium